Earlier this week, Andy Slavitt, Acting Administrator for CMS, told a group of attendees at the J.P. Morgan Annual Health Care Conference that meaningful use is on its way out.

“Now that we effectively have technology into virtually every place care is provided, we are now in the process of ending meaningful use and moving to a new regime culminating with the [Medicare Access and CHIP Reauthorization Act of 2015] (MACRA) implementation,” Slavitt told attendees. “The meaningful use program as it has existed, will now be effectively over and replaced with something better.”

The idea that meaningful use, a program which began in 2011 and aimed to incentivize or penalize physicians for adopting an EHR system, would be over, naturally caused many physicians to celebrate. Melissa Young, an endocrinologist in Freehold, N.J., and a member of the Physicians Practice Editorial Board, e-mailed a three word reaction to the news: “Hooray! ‘Nuff said.”

The AMA had a more formal way of celebrating this news. Of Slavitt, AMA President and CEO, Steven Stack, an emergency physician, told Beckers Hospitals Review in a statement: "He listened to working physicians who said the meaningful use program made them choose between following Byzantine technological requirements and spending more time with their patients. This is a win for patients, physicians and common sense."

In his speech, Slavitt talked about winning the “hearts and minds” of physicians back. Getting rid of meaningful use would undoubtedly help the federal agency achieve that goal, as evidenced by the rising number of docs who opted out of the program due to its stringent requirements. “The concept of meaningful use was always doomed to failure and it has been proven that there is no improvement in the quality of our healthcare delivery system and it has not reduced the costs of the provision of medical care,” Jeffrey Blank, a podiatric physician in Loxahatchee, Fla., and a member of the Physicians Practice Editorial Board, said via email.

Hold that Thought

Despite the excitement, Robert Tennant, health information technology policy director for the Medical Group Management Association (MGMA), says physicians should keep the champagne on ice. For one thing, they will still be judged on EHR and technical capability.

At the conference, Slavitt talked about MACRA, which authorized the creation of the Merit-Based Incentive Payment System (MIPS). MIPS will measure and compensate physicians on quality, practice improvement, cost, and use of technology. Within MIPS will be elements of meaningful use. Rather than rewarding physicians for using technology, MIPS will aim to pay them on using it towards improving their outcomes.

While Tennant says a reworked meaningful use is “potentially very positive,” the guidelines for MIPS are supposed to be released and finalized this year, which he notes could be a problem for physicians. “Payment under MIPS is supposed to take effect in 2019. If the traditional approach of using a two-year look back [to make those adjustments] is in place, it would mean reporting would begin in 2017,” he says. “If you look at the timing from a regulatory process, we’re concerned with how this would be accomplished.”

In essence, vendors would have to redevelop software around the guidelines, train customers, and practices would have to go live within the space of a year. Moreover, Tennant says if MIPS regulations are finalized in December of this year, they’d likely overlap with a new presidential administration.

“Any new administration, the first thing they do is typically put all pending regulations on hold and review them before they approve,” he says. Tennant also notes practices still have to be concerned over meaningful use regulations for 2016, including a full-year reporting period and the fact that Stage 3 of meaningful use is technically supposed to be mandatory in 2018.

“We don’t know what we are moving ahead to,” Tennant says. For practices, he advises to select software that fits their clinical needs and to not worry about “arbitrary and potentially changing” regulations. “Don’t focus on 2017 or beyond. We don’t know. The vendor doesn’t know.”

Even still, he is “cautiously optimistic” about Slavitt’s remarks. “We’re hoping CMS takes this opportunity to leverage MACRA to develop a program that is achievable and clinically relevant,” he says.

Blank is interested to see what lies ahead with government regulations, but is not as optimistic as Tennant. “I'm sure that many interest groups and the insurance industry will profit and doctors like me will continue to struggle,” he says.

Four general policies and developments could help speed up the interoperability initiative.

As a part of a federal mandate to improve EHR use, interoperability, and connected care, the Health IT Policy Committee (HITPC) has submitted its December report to Congress explaining barriers and policy suggestions with regard to interoperability.

Develop Health Information Exchange (HIE) Measures

The first policy suggestion the HITPC explained to Congress was the establishment of HIE-sensitive measures which would not only measure the amount of information providers were exchanging amongst one another, but the meaningfulness and impactfulness of that information. In order for providers to receive high scores on these measures, the information exchanged would need to be used meaningfully, as to reflect an important use of the information.

“In order to enhance the strength of incentives that drive interoperability, a set of specific measures should be developed that focus on the delivery of coordinated care, facilitated by shared information across the entire health team (including the individuals and families) and throughout the continuum of care settings,” the HITPC explained. “An example of an HIE-sensitive measure would look at medically unnecessary duplicate testing.”

This new policy could be effective in strengthening incentives by first allowing payers to incorporate these measures into their payment methods, and second by integrating these measures into public reporting that would in turn reveal which providers give the highest level of coordinated care.

Develop Vendor HIE Measures for Certification

Just as providers should be tested against certain HIE-sensitive measures, as should vendors. Such measures could potentially serve as a direct catalyst to improve vendor developments and performances.

Specifically, HITPC is looking for these measures to occur in practical use -- not in a lab -- and to take into account needs that go beyond certification measures for the EHR Incentive Programs.

“Today, purchasers of EHR systems lack such measures to inform purchasing decisions or to use as a lever to put pressure on vendors to improve,” HITPC confirmed. “Although vendors have strong incentives to pass the interoperability requirements for EHR certification, this process is “one-time” and occurs in a lab. It has not been shown to translate into interoperability that is affordable or easy to implement in the field.”

HITPC also listed a few specific measures that could record vendor HIE performance:

Number of data exchanges from external sources, which could include other providers, community social-service organizations, consumers, payers, etc. (denominator that measures ability to exchange data with another electronic system such as an EHR, HIE or consumer application (app));

Percentage of time viewing of external data changed current activity (e.g., appeared in clinical decision support, led to change in order being written), which demonstrates impact of external data.

Accelerate Incentive Payments for Interoperability

HITPC maintained that in order for providers and vendors to make interoperability progress, they must have adequate incentive payments. Not providing incentive payments encourages providers to deal with internal needs rather than prioritize interoperability.

Today, the lack of palpable financial incentives for interoperability favors the status quo. Pressing internal priorities compete for attention and resources are needed to achieve interoperability, especially when specific actions to enact interoperability are complex and time-consuming. This results in slow progress. Moving interoperability up the priority list will likely take financial incentives that are more targeted than a broad shift from fee-for-service to pay-for- 17 value. To have the desired effect, the incentives must be strong and specific, with clearly defined measures and a deliberate implementation timeline and effective dates.

Initiate Sustained Multi-Stakeholder Action

In order for the above-mentioned goals to be met, HITPC explained that multiple stakeholder groups will need to take action in the overall interoperability efforts. Several of the policy suggestions, such as creating HIE-sensitive provider measures, require multiple voices for development, and multiple interpretations of the ONC Interoperability Roadmap.

Thus, HITPC suggested creating an interoperability Summit of various industry stakeholders in order to collaborate on interoperability efforts.

The output of the Summit would be an action plan with milestones and assigned accountabilities for achieving the milestones in the context of this larger interoperability initiative. We expect the compelling call-to-action would engage the stakeholders to continue their activities after the Summit as a way of meeting the payer-driven incentives that reward HIE-sensitive measures of coordinated care.

Earlier this year, Congress requested a report from the Office of the National Coordinator for Health IT (ONC) which detailed the issues surrounding information blocking. In the report, the ONC both defined information blocking as a practice, and provided examples.

Specifically, ONC defined information blocking as using criteria of interference, knowledge, and lack of justification for refusing to share information.

The information provided in this most recent report from HITPC could potentially put an end to those negative information blocking practices by providing incentives for fostering HIE and interoperability. Between monetary incentives and a clear prescription of HIE measures, both providers and vendors could ideally implement more effective interoperability strategies.

Different EHR vendors perform better in various different countries, according to a new KLAS Global Performance Report.

Despite having distinct popularity and success throughout the United States, Epic Systems is not necessarily the top-performing EHR product throughout the globe, according to a recent KLAS report.

The KLAS Global Performance report breaks down user-perceptions of various different EHR systems by region, such as Asia/Oceania, Europe, Latin America, the Middle East, and North America. Results show that although Epic Systems receives high praise throughout the US, and also performs well in Europe, the vendor does not have a stronghold in other regions.

The the best vendor performances in multiple regions, in fact, belonged to Cerner and Intersystems with high performances in Europe, Asia, and the Middle East.

One of the significant barriers vendors face in implementing their systems abroad are state contracts which limit certain functionality. Several companies, such as Cerner and Intersystems, have trouble implementing in Australia due to contractual issues.

Cerner’s implementation in the UK serves as an example of EHR systems that can be successfully implemented provided full adoption and fewer contractual limitations.

Although Epic is not seeing solid performances or high adoption rates in all regions, it is seeing success at larger health systems in other countries. Of the seven international Epic users interviewed, all of them reported full adoption of the systems, and strong functionality and support.

Vendors that do not see success at larger health systems include Allscripts and Phillips. Allscripts users report complications with implementation and support, while Phillips states that it faces difficulty garnering larger users to adopt their systems.

Cerner has garnered the most success throughout Europe, with the most ubiquitous successful adoption throughout the entire continent. That said, Epic has nearly 100 percent approval ratings from European users, though they are almost entirely located in one nation (the Netherlands).

As previously stated, Cerner’s clients in Australia are having difficulty with implementation. This is because of the way in which user contracts are established. Reported issues include a need for increased functionality, more system training, and increased systems optimization.

Despite Epic’s inconsistent international ratings, the EHR vendor continues to prove successful in the US. Between Epic’s many users’ awards, as well as Epic’s own honors, the vendor maintains its foothold as a health IT giant.

Additionally, Epic won out in a recent Peer60 study of the physician-ranked most innovative EHR systems. Among the C-suite executives surveyed in the study, Epic won out as the overall best EHR system in operation. The vendor was also selected as one of the most intuitive and easy-to-use models on the market, and the top choice for CIOs.

Cerner and its users were also successful in the US this year, receiving KLAS’s best small ambulatory EHR award for 2014. Cerner also received two other KLAS awards in 2014.

In the aforementioned Peer60 study, Cerner was ranked as one of the most intuitive models on the market, as well as a top choice for COOs.

Perhaps most notably, Cerner was recently selected as the choice EHR for the Department of Defense EHR modernization project in partnership with Leidos Partnership for Defense Health. The partnership, which is currently valued at approximately $9 billion, was a significant feat for the EHR vendor.

“The Leidos Partnership for Defense Health is honored to have partnered with the Military Health System for nearly three decades, and we are committed to continuing our work in support of its mission to improve the health and medical readiness of our military,” Leidos representatives said in a public statement. “Our team stands ready to lean forward with the DoD to implement a world class electronic health records system.”

Several weeks following the implementation of the ICD-10 code set, the progress of the transition appears to vary according to size of the practice. While many large practices are reporting success with the transition, some smaller ones are reporting difficulty.

According to a blog post by the Coalition for ICD-10, many of the group’s members -- which happen to be larger healthcare providers -- are reporting great success with the transition. Many, like Centegra Health System, credit this success to the ample time for preparation they received.

“Centegra Health System was prepared for a smooth ICD-10 transition after two years of careful planning. Our information technology systems have been updated and our educational plans were deployed to help with the initial roll-out,” said Centegra’s Executive Vice President, Chief Financial Officer, and Chief Information Officer David Tomlinson.

Additionally, some coalition members stated that their success on October 1st is due in large part to their early implementation of the code set.

“Northwest Community Healthcare’s transition to ICD-10 has been smooth. This is due, in part, to our early clinical rollout of ICD-10 with our Epic Go-Live date of May 1, 2015,” said President and Chief Executive Officer of Northwest Community Healthcare Stephen Scogna.

Other members of the coalition, such as insurer Blue Cross Blue Shield of Michigan, reported a few bumps in the road amidst a generally smooth transition.

““BCBSM’s ICD-10 implementation went very smoothly. Call center volumes and overall inquiries are very low. Professional and facility claims are processing as expected. A few issues noted, which we are resolving, but nothing major to report,” the insurer said.

BCBSM also reported that it was the first private insurer to reimburse the hospitals it serves.

“Received kudos from our hospitals stating that BCBSM was the first payer to pay ICD-10 claims and these claims are paying as expected. Hospitals are not reporting any major issues. Other Payers (Priority, Cigna, Aetna) are reporting the same experience in that they are not seeing any major issues.”

However, this success is in contrast to what some other smaller providers are reporting. The impact of ICD-10 on smaller providers is a little bit more weary as these providers have fewer resources to work with.

For example, Linda Girgis, MD, FAAFP, told EHRIntelligence.com that due to how small her practice is -- she and her husband are the only physicians in the family practice -- its workload has grown much larger. This work includes changing patient problem lists from ICD-9 codes to ICD-10.

"The doctors are doing it right now," she says. "I'm doing it as I come across different patients, but definitely it's adding time on to the workday."

Smaller practices are especially affected by ICD-10 troubles because much of their revenue comes from the Centers for Medicare & Medicaid Services (CMS), and the agency has been reportedly unreachable throughout the transition.

"My biller tries to call every day. Since October 1, they have messaged that they are down due to technical difficulties so it's impossible to get through to any person there,” Girgis said.

Not receiving CMS payment is problematic for small practices like Girgis’ because those payments may amount to almost 30 percent of hospital revenue. While a larger hospital, like those mentioned above, may be able to do without 30 percent of its revenue for a month or two, this kind of issue could be potentially detrimental for a practice like Girgis’.

"Big organizations, hospitals, and groups can go a few months without 30 percent of their reimbursement coming in. But for small practices, that can be devastating," argues Girgis.

CMS set a timeline for rolling out ICD-10 payments, stating that those claims would be reimbursed within the first 30 days of the new code set. As that 30-day timeline draws to a close, small practices will be waiting to see if their claims are reimbursed.

EHR interoperability has been brought to the forefront lately as various health organizations and government agencies push for nationwide health information exchange. Furthermore, as integrated healthcare and care coordination become fixtures in the healthcare delivery industry, interoperability of systems between different kinds of practitioners shows itself to be critical.

A recent study by Maribel Cifuentes, RN, BSN, Melinda Davis, PhD, Doug Fernald, MA, Rose Gunn, MA, Perry Dickinson, MD, and Deborah J. Cohen, PhD, discussed how EHRs operated in 11 practices that were integrating the delivery of primary and behavioral healthcare. The researchers found that when behavioral health and primary care begins to integrate, the two kinds of practitioners brought separate EHR systems with them. This caused challenges and subsequent workarounds and solutions associated with EHR interoperability.

The study took 11 integrated practices in the Colorado area and gathered data regarding how EHRs worked for their needs, the challenges practices faced, what kinds of workaround strategies practices developed, and what kinds of long-term solutions the practices identified in order to promote care coordination over an EHR.

One of the challenges many of the integrated practices faced was that the EHRs were not necessarily designed to collect a certain kind of data. For example, in a primary care facility that hired several behavioral health counselors (BHCs), the facility’s EHR may not have been conducive to collective behavioral health data.

Third, many EHRs were not interoperable with each other, hindering primary care physicians and BHCs from working together in delivering coordinated care. The EHRs were also not compatible with tablet devices that were used to collect behavior health information in the waiting room prior to appointments. These tablets were used to present questionnaires that would provide behavioral health data. However, the lack of interoperability between these devices and EHRs made it so the data collected in the questionnaire could not easily be uploaded into the EHR.

The study reports four workarounds that were developed in the face of these challenges. First, as stated above, when the primary care and behavioral health practices first integrated, the physicians often had their own separate EHR systems. In order to make sure both systems had patient information, physicians had to manually enter the data into both EHRs. While this method may have been effective in ensuring patient information was stored in both EHRs, it was not particularly time or financially effective.

Second, medical assistants had to manually scan printed documents into EHRs. While this method may have also been effective, it presented several time and financial issues. Furthermore, the scanned documents were often harder to find in the EHR, hindering the physician from delivering care to patients in a timely manner.

Third, practitioners relied on patients and other physicians to recall patient information. This workaround was not effective because patient and physician memory was neither reliable nor accurate. One physician reported having to recall patient information that was told to him several weeks before meeting with the patient. Due to the amount of time that had passed since he had last discussed this patient, he was unable to determine what kinds of services the patient needed. This resulted in the patient taking tests that had already been administered.

Fourth, practitioners employed “freestanding tracking systems,” such as spreadsheets, that were not a part of the EHR. For example, one practice stored information regarding adolescents taking selective serotonin reuptake inhibitor medications in an Excel spreadsheet. Although this was widely used amongst the practice, it took enormous effort from practitioners to maintain, and the information on the spreadsheet was not easily integrated into the EHR.

By the end of the study, researchers observed that practices began moving past workarounds and toward more long-term solutions to their challenges in order to make their integrated practices more sustainable in the future. The researchers noted that these solutions were created by each practice’s own HIT teams and required their own funding. Three key solutions amongst the participating practices emerged.

First, many practices created their own customized EHR templates. These templates existed within their pre-existing EHR systems, and simply added more fields for data entry that would be more suitable for practitioners’ needs. However, developing these templates was an arduous task.

“Creating customized EHR templates was time consuming and required dedicated HIT staff working collaboratively with BHCs and primary care providers,” the researchers reported. “Practices that did not have access to these resources were not able to create customized templates as readily, or had to pay EHR vendors to do so.”

Second, some practices purchased EHR upgrades and reported several improvements from doing so, including increased interoperability, enhanced reporting templates, and more interfaces for integrating primary and behavioral health care.

However, EHR upgrades were considerable financial investments for practices. Practices were not allowed to upgrade their EHRs using the money allocated to them by participating in the study, so the upgrade needed to be a part of the individual practice’s investments. This financial burden made it so only five of the 11 participating practices were able to upgrade their EHRs.

The final emerging solution was the union of two EHRs. At the start of the study, four of the 11 participating practices were using two different EHRs -- one for behavioral health care and one for primary care. By the end of the practice, three of them were in the midst of merging those two EHRs, and one had built an interface that extracted data from multiple EHRs and stored the data in one place. While these solutions were quite complicated and costly, they were the most effective in overcoming interoperability challenges.

Despite the advances these practices made, the researchers maintained that integrated providers may still face hurdles in the future.

“EHR systems are not yet optimally designed to meet the needs of practices integrating behavioral health and primary care,” the researchers stated. “Our study found that EHRs generally lack features essential to support key integration functions such as documenting and tracking longitudinal data, working from shared care plans, and template-driven documentation for common behavioral health conditions such as depression.”

The researchers provided guidance on how to improve EHR use in integrated care situations, stating that perhaps systems need to start being designed for integrated care, as should different incentive programs.

“In the future, HIT systems should be intentionally designed, in cooperation with clinicians; to support and enable these integrated care functions, as well as the different modes of communication and care coordination tasks that occur between multi-professional members of integrated teams,” the researchers maintained.

Furthermore, the researchers stated that more financial incentives should be provided to allow practices to make these kinds of changes. Although several EHR and interoperability incentive programs exist, none of them provide incentives that would help practices change their EHR systems to make it more usable in an integrated practice.

EHR use presents many healthcare benefits, including coordination of care and increased patient engagement. However, , the lack of EHR and health IT interoperability is posing a serious threat to other healthcare initiatives, according to a recent report published by the American Hospital Association.

The report, entitled Why Interoperability Matters, discusses the various aspects of the healthcare industry and care delivery that are negatively impacted by a lack of interoperability. Among those aspects include care coordination, patient engagement, and public health and quality measures reporting.

Care coordination

The exchange of health information is critical for the coordination of care, according to AHA. When patients receive care from multiple different providers, physicians should be able to securely send relevant patient information to the practicing physician. However, that tends not to be the case because EHR systems are not interoperable and cannot exchange information.

Furthermore, care coordination and successful interoperability are vital for provider finances. As accountable care organizations and bundled payments continue to grow more prevalent, the AHA maintains that interoperability and the ability to see all of the care a patient in receiving is crucial in preventing unnecessary treatment.

Patient Engagement

Patient engagement and the shared decision-making between providers and patients is critical in achieving the aims of the healthcare industry, the authors of AHA report maintain. Further, patient engagement is a central part of federal regulations on using an EHR. However, the agency states that many patients are unable to access their electronic health information, hindering the practice of patient engagement.

“The real problem is that the vast majority of patients cannot access their health information in a holistic, meaningful way. Instead, they must go to each of their providers’ patient portals and download unintegrated data. Making sense of this, particularly for patients with multiple chronic conditions who frequently have many health encounters a year, is difficult,” the report states.

Public Health and Quality Measures Reporting

EHR use also provides the opportunity for enhanced public health reporting. Because patient data is aggregated on one, electronic system, healthcare professionals can track healthcare trends and analyze information about population health. But without adequately interoperable systems, that process is significantly hampered.

“Hospitals are happy to report this data to improve public health but must contend with a wide variety of reporting formats and transmission technologies to do so, including faxing, mailing, e-mailing, web forms and secure file transfer protocols,” report reads.

Healthcare providers have created a few solutions to this interoperability problem, including interfaces and health information exchanges.

Interfaces are programs that allow a facility’s EHR to pass along information from one system to another, yet practices face challenges when using interfaces for more than one provider.

“...in health care, each interface currently is like a snowflake: it must be built to meet the unique requirements between two providers and cannot be reused,” the authors explain.

Because practices would need to adopt multiple interfaces, they are not always a financially stable solution to interoperability.

Like interfaces, health information exchanges (HIEs) have presented themselves as potential solutions to interoperability problems. Although HIEs can be successful in securely transmitting health information between providers, they too are quite costly. Furthermore, AHA explains that many HIEs are installed via federal grants, and that when the grants run out, many practices are unable to maintain their HIEs.

Health IT standards need more specificity

Although there are a set of standards identified for the use of EHRs and other health IT, they are not specific enough to be effective, the authors note. Creating uniformity in how data is collected and stored on an EHR, however, would be a drastic step forward for interoperability, the report states. Increased health IT standards would cause data to be input in the same way across the healthcare delivery spectrum, making information sharing more feasible.

Although the authors acknowledges the potential that health IT standards have in increasing interoperability, the agency maintains that much work in defining those standards and developing other platforms needs to be done before the industry can achieve nationwide interoperability.

Throughout my HIM career, I have seen many different methods of capturing clinical documentation. We are always looking for solutions to get accurate and complete clinical documentation into the medical record in a timely manner with minimal disruption to the provision of care. The processes for gathering documentation have evolved with advances in technology and HIM professionals have been very involved in ensuring the quality of the documentation.

When I first began working in an HIM department, we had a Transcription department with hospital-employed transcriptionists and a management team devoted to medical transcription. Quality reviews were performed regularly and the transcriptionists had an ongoing relationship with the physicians to provide feedback and get clarifications. As part of this department, there were file clerks in charge of filing the transcribed documents onto the paper medical records throughout the day and into the night. When I think back on these practices, it seems like an entirely different lifetime from today’s practices yet it really wasn’t that long ago.

Over time, transcriptionists began to disappear from hospitals as the task became outsourced. Vendors have offered to do the job for less cost and they guaranteed a high quality rating of the transcribed reports. However, transcribed reports often still come back to the medical record with blanks and anomalies that must be corrected by the dictating clinician which can delay the documentation reaching the chart. It’s important to review documents to make sure there are no obvious errors that may have been misinterpreted by the transcriptionist or the back-end speech recognition system.

Many are still relying on outsourced transcription as a major source of capturing documentation but this is evolving as EHRs have created new opportunities for documentation. EHRs provide documentation tools such as templates to import data into the notes and allow for partial dictation for the narrative description. The negative side of this is that copy and paste is used frequently due to the ease of grabbing documentation from the rest of the EHR and pasting it into the note to save time. Clinicians using copy and paste may not realize that the information could be outdated or it could be against company policies. This now requires quality reviews to monitor the use of copy and paste and the relevance of the documentation to maintain the integrity of the medical record. This should be incorporated into chart audits or other quality review processes.

Front-end speech recognition tools are popping up frequently as an additional tool to capture documentation. A concern with this is the shift from having quality reviews performed by the transcriptionist to now relying on the clinicians to edit their documentation as they dictate. Many are creating positions in HIM departments to perform quality reviews on the documentation to not only ensure the documentation is in the record in the adequate timeframe but making sure the documentation is accurate for each patient. It will be interesting to see how clinical documentation continues to evolve as new methods of capturing documentation are developed and deployed. No matter how the information gets into the medical record, HIM professionals still have the ultimate responsibility to ensure the quality of the documentation for patient care and appropriate reimbursement.

Larger EHR vendors tend to make better partners in achieving Stage 2 Meaningful Use, according to a recent study by Peer60. The study, which discusses insights and trends in EHR vendors, sought to identify the which vendors play a bigger and more supportive role in providers’ work to achieve meaningful use.

According to the report, users of notable vendors such as Epic, Cerner, and Allscripts stated that these technology partners delivered adequate support for their efforts to meet meaningful use. Among these vendors, many users also reported being in the midst of attesting to Stage 2. Epic also had several respondents report that it was not an adequate partner in Stage 2 attestation, but given the high volume of users Epic engages with, the positive reviews significantly outweigh the negative.

Other vendors did not receive such favorable reviews, according to Peer60. Among those is McKesson, who received nearly double the percentage of negative reviews as positive ones. McKesson also has a substantial number of users who report still being in the process of attesting Stage 2. A few smaller vendors also received negative meaningful use reporting reviews, including NextGen and Practice Partners (which is owned by McKesson).

Of the practices surveyed, nearly 90 percent of them have either achieved Stage 2 or are in the middle of attestation. Fifty-six percent of respondents had successfully completed Stage 2 attestation, and 34 percent were in the thick of attesting. Only 10 percent had not successfully attested, and Peer60 reports that about half of those who had not been successful “simply don’t have the proper model to receive enough benefits to bother attesting.”

This report comes out after CMS released data regarding meaningful use registration and participation. Given that data, it appeared as though the delay in the release of the meaningful use modificationrules was hindering program growth. According to CMS, meaningful use enrollment stayed stagnant between the months of May and August. Medicare eligible professional (EP) enrollment also remained relatively the same between May and July, and skyrocketed in August. Likewise, eligible hospital (EH) enrollment stayed consistent between May and July and made a notable jump in August.

Now that the Stage 2 Meaningful Use Modifications Rule has been released, the rate of EHR Incentive Program enrollment may increase. Because the modified rule eliminates unnecessary and cumbersome requirements, as well as shortens the initial reporting period to 90 days, it is expected that more providers will enroll in the program and will be able to achieve success.

However, success could potentially be better facilitated by an EHR vendor that is more supportive and provides a product that works better with meaningful use. As such, EHR vendors may need to adjust their practices in helping providers meet meaningful use guidelines in order to remain competitive in the EHR market.

At a time when American providers are offering some of the best care in the world, even the smallest medical practices cannot slip. They must offer top-tier services, while meeting and maintaining compliance with government regulations. This is no small order, and it's made increasingly difficult considering the price tag that comes with integrating cutting-edge technology — in particular, EHRs — into an office, especially for solo practitioners or practices with just a handful of doctors.

While the incentive to invest is greater than ever with the ongoing meaningful use program, the cost of implementation is still pricey. Physicians working in the smallest practices have to get creative when trimming technology expenses.

KEEPING COSTS IN CHECK

"Maintaining an electronic health record system is our largest expense," says pediatrician R. Frerichs of North Raleigh Pediatric Group. His practice isn't an isolated case. According to a survey in Medical Economics from February 2014, 45 percent of physicians spent more than $100,000 on EHR systems including service, hardware, software, training, and consulting. However, there are ways to shrink that number considerably.

It is easy to feel overwhelmed by options available in the marketplace. Practices on the hunt for tech investments must be mindful of what is specifically needed. "There is a want to measure everything without knowing why or what to do with the measurements," says Kyle Wailes, senior vice president of physician services at the Ft. Lauderdale, Fla.-based technology solutions provider, Intermedix. "A smart and focused practice can avoid much of this by determining must-haves ahead of time and knowing exactly what is needed when purchasing technology."

In addition to searching for the product that best matches a practice's needs and work flow, there is value in adopting open source products. Dozens of open source software programs have been developed for the medical industry with data security and usability at the forefront, says Greg Scott, owner and operator of Infrasupport Corporation, an IT consulting firm in Eagan, Minn. With open source software, physicians don't have to become IT experts, since someone else developed the software and the additional features. They do have to be willing to explore technology built using an open source model by accepting patches, new features, and other support built by an interested community. Any potential inconvenience is likely to be offset with the cost savings, which can be as much as 80 percent compared to proprietary competition, Scott says.

Similarly, practices should seek out "disruptive vendors" — those working on the innovative edge of mainstream technology — because they typically have lower gross margins, smaller target markets, and simpler products, experts say. Though the products and services may not appear as attractive as existing solutions when compared against traditional companies, the cost is often cheaper, says Austin Kirkland, principal and founder of healthcare management services consultancy Outperform, LLC, based in Falls Church, Va. "Many businesses have developed software tailored to suit specific specialties or to operate with less robust features, lower development costs, and reduced operating overhead," he says. "As a result, they are able to offer their products at a better price point to specific buyers than their larger competitors, so shopping for the right solution can save money."

Once practices have made the initial investment for EHR and practice management systems, there are ways to manage the ongoing costs associated with overseeing them. The unfortunate truth is that technology requires constant upgrading to remain efficient and compliant, which of course, comes at a cost. Instead of hosting technology infrastructure onsite at a practice, medical offices should consider migrating most (if not all) technology services to a cloud services provider or third-party data center. Doing so requires an initial upfront cost, but service fees are generally paid monthly at a predictable, scalable rate. Additionally, this frees medical practices from worrying about hardware failures or updating software because managing those responsibilities falls to a third-party vendor.

SHRINKING PAYMENTS IN A SMALL PRACTICE

Despite doing due diligence to select the best and most cost-effective products and maintenance options for a small practice, the fact is that someone still has to pay the bill for technology.

One of the best things practices can do is find support within a larger group of physicians. Frerichs says his participation in a practice management group called Raleigh Durham Medical Group (RDMG) has been a critical factor in his ability to manage costs for his practice. "The power in numbers allows us to negotiate deals for pricing that I would not be able to attain alone," he says. For example, he adds, collaboration through RDMG allowed them to obtain optimal pricing for purchasing an EHR. Furthermore, when the need to replace or update equipment arises, the group provides flexible financing options.

Flexible financing also allows physicians to relieve some of the weight that comes with buying technology outright. For practices that don't have credit available to take term loans — or those that simply choose not to — leasing options are available. This ensures practices have cash on hand to pay for consumables, payroll, fees and taxes, and other necessities, says Jim Phelps, CEO of Beaverton, Ore.-based equipment financier, Capital Equipment Leasing, and it keeps a line of credit open for other needs. Leasing also removes the permanence that comes with an outright product purchase, allowing companies to upgrade or change technology with minimal cost. "Software and hardware can be leased on a turn-key basis, allowing the practice flexibility as needed to move at the end of a lease and to avoid upfront capital needs," Kirkland says.

Though hardware and software can be leased, other products can as well. Phelps' company has leased digital X-ray, sonogram, and MRI machines, and exam tables. "We can lease any equipment that is not 'body invasive,'" he says.

Investing in technology, whether hardware and software, diagnostic equipment, or other necessary products and services, is a given in the medical industry. Small practices must be innovative to keep on top of advances in the industry, because the ultimate bottom line is providing the very best care to each and every patient.

On October 1, the healthcare industry began ICD-10 compliance after countless months of preparation. In a CMS post, Deputy Administrator and Director of the Centers for Medicare & Medicaid Services (CMS) welcomed providers to ICD-10 and provided words of guidance to industry stakeholders on the transition day.

According to Cavanaugh, it may take a little while before CMS is able to assess how the transition to ICD-10 is proceeding. The reasons for this are twofold: first, most providers do not file claims on the same day as a service has been provided, and second, it takes a few weeks for CMS to process Medicare and Medicaid claims.

“Even after submission, Medicare claims take several days to be processed, and Medicare -- by law -- must wait two weeks before issuing payment. Medicaid claims can take up to 30 days to be submitted and processed by states,” Cavanaugh wrote.

It is most likely that CMS will be able to assess ICD-10 progress following the first complete billing cycle. This is consistent with other CMS claims. In aconference call with industry stakeholders which took place a week before the October 1 deadline, CMS Principal Deputy Administrator Patrick H. Conway, MD, MSc, confirmed the same timeline for checking ICD-10 progress.

Until then, Cavanaugh explained, CMS plans to closely monitor the transition. Furthermore, CMS will be managing problems and questions that are submitted to the ICD-10 Coordination Center, which is staffed by several Medicare, Medicaid, billing, coding, and health IT experts to assist during the transition. In addition to the ICD-10 Coordination Center, Cavanaugh points providers toward other ICD-10 assistance resources, including William Rogers, MD, the ICD-10 ombudsman, and Medicare Administrative Contractors (MACs).

Cavanaugh also discussed the potential benefits of the ICD-10 transition, including the promise of more detailed health data reporting and and better healthcare delivery. By increasing the detail with which medical care is reported, policy changes can be more specific to the needs of populations.

“The change to ICD-10 allows you to capture more details about the health status of your patients and sets the stage for improved patient care and public health surveillance across our country,” he wrote. “ICD-10 will help move the nation’s health care system to better, smarter care.”

These hopes for ICD-10 have been mirrored by many industry stakeholders, including AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA. Thomas Gordon recently stated howICD-10 will be of great benefit for patients because it will allow for better healthcare innovation due to the extensive detail of health records.

“As an active leader, supporter and advocate for ICD-10, AHIMA is pleased that the greater detail inherent in the code set will reverse the trend of deteriorating health data and tell a more complete and accurate patient story,” she said.

As providers continue with their transition to ICD-10, CMS is expected to report any major issues and provide guidance in fostering the smoothest transition possible.

The ICD-10 compliance deadline of October 1 is less than a week away, creating a frenzy of preparation amongst coders, billers, and providers. The Centers for Medicare & Medicaid Services (CMS) senior officials recently held a conference call to answer questions regarding implementation, and specifically addressed the issue of CMS as a resource come October 1.

The bulk of the call consisted of a question and answer session which generally revolved around the roll of CMS as a resource for clinician practices experiencing issues with transition. Specifically, many callers were concerned with the potential government shutdown that could occur on October 1 if Congress cannot reach an agreement on the federal budget.

“In the event of a shutdown, we will continue -- and I want to be clear on this -- to pay claims,” Conway said. “We will continue to implement the ICD transition.”

Rogers made it clear that the Medicare administrative contractors (MACs) would still be working in the event of a shutdown, so claims will be accepted and paid during that time.

Conway elaborated on that point during another question, stating that payment systems are an essential part of the Medicare program and would still function in the event of a shutdown.

“In terms of staffing, we do have the flexibility to ensure core operations are operational and in effect,” Conway stated. “And obviously, our payment systems are a core piece of the Medicare program that will continue to be fully operational.”

Conway also addressed the issue of claims processing timelines and how that will affect real-time assessments of the transition. Although it would be ideal for CMS to have a clear idea of the state of the transition as soon as it occurs, Conway explains that due to the typical billing timeline, it will in reality take about one billing cycle.

“The Medicaid claims can take up to 30 days to be submitted and processed,” he said. “This end can take approximately two weeks. The Medicaid claims can take up to 30 days to be submitted and processed. For this reason, we expect to have more detailed information after a full billing cycle is complete.”

The questions on the call revolved around the cost of ICD-10 implementation, especially considering systems upgrades. According to Conway, the cost greatly relied on the specific circumstance of the practice or facility. Rogers shed light on the costs for smaller practices.

“[M]ost smaller practices just use a super bill,” Rogers explained. “t requires a little bit of an expansion of the number of diagnoses on the superbill. But they can easily cross walk their ICD-9 based super bill to an ICD-10 super bill.”

Rogers also assured callers that CMS has ample resources to ensure a smooth transition, and that they themselves will be able to serve as a resource for clinician practices. He explained that he, along with all of CMS, can serve as a major resource for providers who have questions regarding the transition process, and encourages providers to contact the ombudsman email address when in need of assistance.

Not only are healthcare organizations looking for EHR replacement technology for primary care providers and affiliated physician networks, but they also are planning to switch vendors for their emergency department information systems (EDIS), according to recent survey of more than 400 emergency medicine providers by peer60.

One-third of hospitals intend to change their EDIS in the near future. “Providers are increasingly adopting an enterprise vendor approach, meaning, some vendors will be moving toward their EHR vendor’s EDIS,” the report states.

Currently, the leaders in EDIS market share are MEDITECH, Epic Systems, and Cerner Corporation, which combined control close to 50 percent of the marketplace. Despite this reality, market leader MEDITECH trails behind Epic and Cerner significantly in terms of provider perception. Close to 80 percent of respondents believed Epic and Cerner as the “true master of EDIS when considering market share and mind share together.”

Over the past two years, a large majority of respondents (82%) reported an increase in the number of visits to the ED, with a similar amount reporting that the number of ED visits will increase although not significantly:

When comparing what happened over the last two years with what will happen over the next two years, a relatively small portion of providers predict an increase of over 10% in the next two years. An increase of over 10% was seen by 31% of providers over the past two years, vs. 17% of providers over the next two years. A lack of primary care providers and an increase in insured patients have created a perfect storm for patients who have little choice but to turn to the ED for treatment.

This prevailing opinions are expected to have a significant impact on other EDIS vendors competing in the space. “When broken down by facility size, both Epic and Cerner consistently maintain top three positions in both market share and mind share. Best of breed vendors struggle to make a substantial impact in the EDIS market,” the authors of the report claim.

Despite their perceived dominance in the EDIS space, Cerner and Epic are among other EDIS vendors in danger of losing clients. The report adds Allscripts, athenahealth, CPSI Healthland, McKesson, MEDHOST, MEDITECH, NextGen, Optum, and T-System to that list.

Likely motivating the EDIS replacement trend is a lack of satisfaction among emergency department leadership in their current EDIS vendors. The average score on ten-point scale for EDIS clients recommending their vendors to others was 5.7.

EDIS vendors, however, do have the opportunity to maintain their clients. Top of the list of emergency provider wants is improve usability (49%), followed by improved reporting (32%), a more robust platform (26%), and improved customer service (23%). Cost was not a leading factor at 15 percent. These demands aside, one-third of respondents maintained that their current EDIS vendors could do nothing to keep them.

This story begins, as many do, with a real-world experience. Our health plan just refused to pay for a sleep study for my husband, who suffers from severe sleep apnea, despite his being quite symptomatic. We’re following up with the Virginia Department of Insurance and fully expect to win the day, though we remain baffled as to how they could make such a decision. While beginning the complaint process, a thought occurred to me.

What if wearables were able to detect wakefulness and sleepiness, and my husband was being tracked 24 hours a day? If so, assuming he was wearing one, wouldn’t it be harder for a health plan to deny him the test he needed? After all, it wouldn’t be the word of one doctor versus the word of another, it would be a raft of data plus his sleep doctor’s opinion going up against the health plan’s physician reviewer.

Now, I realize this is a big leap in several ways.

For one thing, today doctors are very skeptical about the value generated by patient-controlled smartphone apps and wearables. According to a recent survey by market research firm MedPanel, in fact, only 15% of doctors surveyed see wearables of health apps as tools patients can use to get better. Until more physicians get on board, it seems unlikely that device makers will take this market seriously and nudge it into full clinical respectability.

Also, data generated by apps and wearables is seldom organized in a form that can be accessed easily by clinicians, much less uploaded to EMRs or shared with health insurers. Tools like Apple HealthKit, which can move such data into EMRs, should address this issue over time, but at present a lack of wearable/app data interoperability is a major stumbling block to leveraging that data.

And then there’s the tech issues. In the world I’m envisioning, wearables and health apps would merge with remote monitoring technologies, with the data they generate becoming as important to doctors as it is to patients. But neither smartphone apps nor wearables are equipped for this task as things stand.

And finally, even if you have what passes for proof, sometimes health plans don’t care how right you are. (That, of course, is a story for another day!)

Ultimately, though, new data generates new ways of doing business. I believe that when doctors fully adapt to using wearable and app data in clinical practice, it will change the dynamics of their relationship with health plans. While sleep tracking may not be available in the near future, other types of sophisticated sensor-based monitoring are just about to emerge, and their impact could be explosive.

True, there’s no guarantee that health insurers will change their ways. But my guess is that if doctors have more data to back up their requests, health plans won’t be able to tune it out completely, even if their tactics issuing denials aren’t transformed. Moreover, as wearables and apps get FDA approval, they’ll have an even harder time ignoring the data they generate.

With any luck, a greater use of up-to-the-minute patient monitoring data will benefit every stakeholder in the healthcare system, including insurers. After all, not to be cliched about it, but knowledge is power. I choose to believe that if wearables and apps data are put into play, that power will be put to good use.

The American Health Association (AHA) is the latest industry group to share its recommendations for changes to meaningful use requirements following the publishing of modifications to Stage 2 Meaningful Use and requirements for upcoming Stage 3 in October by the Centers for Medicare & Medicaid Services (CMS).

As a result, it's worthwhile in light of the AHA's most recent comments to recap the similar recommendations made by these industry groups representing large constituents of healthcare organizations and professionals.

"Experience to date indicates that the transition to new editions of certified EHRs is challenging due to lack of vendor readiness, the necessity to update other systems to support the new data requirements, the mandate to use immature standards, an insufficient information exchange infrastructure and a timeline that is too compressed to support successful change management," AHA Executive Vice President Thomas P. Nickels states.

Postponing the start of Stage 3

Neither AHA nor CHIME wants the next stage of the EHR Incentive Programs to begin prior to 2019. For its part, the former is seeking alignment between meaningful use requirements and those likely to come out of the Medicare Access and CHIP Reauthorization Act (MACRA).

Both organizations have pointed to provider struggles with previous stages of meaningful use as proof that the program's timeframe does not reflect experience-to-date of eligible hospitals and professionals whose success in Stage 1 did not carry over into Stage 2.

"All providers require sufficient time to implement and upgrade technology and optimize performance before moving to more complex requirements for use," adds Nickels.

Eliminating all-or-nothing approach

The American Medical Association (AMA) was likely the first industry group to advance this notion, but it now has company.

AHA, CHIME, and the aforementioned organization all seek the removal of the all-or-nothing thresholds required by the EHR Incentive Programs. AHA goes so far as to set the bar at 70 percent for EPs and EHs in successfully demonstrating meaningful use.

Reducing reporting burden on providers

Here AMA and CHIME are in agreement. The former was much more explicit in calling on CMS to allow providers to get the most out of the data they already have that can be used for the EHR Incentive Programs, Alternative Payment Models (APMs), and the Merit-based Incentive Payment System (MIPS).

Advancing interoperability

AHA, CHIME, and AMA all agree that Stage 3 needs to play a significant role in advancing interoperability and therefore must change significantly in order to do so.

For AHA, it's about use cases. "Prioritization of use cases that accelerate the exchange of the current meaningful use data set that is being captured to support care will build confidence and support for tackling the capture and exchange of additional data elements," writes Nickels.

Echoing AMA, the organization emphasized the need for more time for the healthcare and health IT community to address the issue. "The AHA urges CMS to allow the current market pressures for information exchange from consumers and from new care delivery models to accelerate demand for information exchange," added Nickels.

Many more recommendations comprise the letters from these industry groups to CMS, but a consensus is growing more steadily for some changes.

"Having accomplished the significant goals of greatly expanded EHR adoption and baseline interoperability via Direct, but also having alienated almost the entire health care provider community by overreaching for the final, Stage 3 version of its regulations, the Meaningful Use programs will be phased out by the end of 2016," the organization maintained in a public statement. "Providers are particularly worried because the requirements of Stage 3 MU do not align well with MIPS and MACRA, the new rules under which Medicare will pay for value and performance, rather than for volume of care."

DirectTrust sees things playing one of two ways.

"It may occur as a result of massive defections by providers willing to face fee schedule penalties rather than spend more resources on health IT that doesn’t add value to their practices and hospitals, it continued. "Or, it may happen as a result of Congressional action, or because CMS and ONC see the hand-writing on the wall and scale down and bow out gracefully."

The organization's prediction echoes the sentiments of Beth Israel Deaconess Medical Center CIO John D. Halamka, MD, MS, who less than a month ago asserted that meaningful use had served its purpose and ought to give way to Medicare Access and CHIP Reauthorization Act (MACRA).

Similarly, both DirectTrust and Halamka consider the lofty aims of Stage 3 Meaningful Use are sufficient cause for moving away from the federal program.

Elsewhere in its health IT predictions for 2016, DirectTrust expects patients to take on a more significant role in ensuring the electronic exchange of their health data:

Patients will have greater access to their clinical records, and they will be able to more freely and easily move those records whenever and to whomever they choose. Health care consumers will take as their right control of their own health information in much greater numbers. The corresponding willingness of provider organizations to permit this patient engagement — and to view it as positive and productive to attaining better health outcomes — will also become more evident across the U.S.

The consequence will be a freeing of data and an increased focus on patient-facing applications although it may not go as smoothly as desired.

"This will not happen linearly; rather it will grow explosively, and then suffer hiccups and setbacks as the privacy and security risks of such systems are first exposed, and then dealt with. But it is going to happen," the group added.

This is likely to tie in with another of its predictions — the coming to the fore of health data security and privacy in 2016.

"The cost of data breaches in health care is simply too high to be tolerated," DirectTrust stated. "As use of electronic health information exchange soars, we will experience a corresponding rise in concern about and actions taken to mitigate the risks of exposure of both data at rest and data in transit. Parties involved in electronic data exchanges will insist on more and more rigorous certification, accreditation, and audit of security and identity controls as a first condition of participating in data sharing."

In its remaining predictions, the organization anticipates a movement toward greater interoperability on the part of federal and state agencies as well as a growing reliance on Direct exchange for enabling the secure and interoperable movement of health data between and among providers for the purposes of care coordination.

EHR and practice management (PM) systems come with built-in reporting capabilities but digesting all that information can be overwhelming. However, leveraging the power of Excel to sort and manipulate the data stored in your EHR can help you spot trends faster and implement steps to drive revenue growth.

“Excel is a great way to slice and dice your practice management data so you can really use it to improve,” says Nate Moore, CPA, MBA, an independent consultant and coauthor of “Better Data, Better Decisions: Using Intelligence in the Medical Practice.” “Excel allows you to filter, trend, and get your arms around reams of data.”

Excel offers an interactive tool called pivot tables that allow users to quickly sort, filter, and manipulate data, says Moore, who moderates the Excel Users Medical Group Management Association Community, an online resource for practice administrators. It gives users much more flexibility than an EHR, which typically offers a limited number of canned reports.

For example, your PM system can probably produce a general report on your collection rates at the front desk at the point of service. But a pivot table would allow you to slice that data in a variety of ways, such as individual employees’ collection rates by location or time of day.

In addition, you can connect Excel to the server where your data is stored so you are always working with the most current numbers, says Moore. That allows you to quickly run the same types of reports with updated data.

“A lot of practice administrators don’t run reports as often as they’d like because they take so much time to run and analyze using the PM and EHR,” says Moore. “Using Excel streamlines the process, making it more likely that reports will actually get produced.”

Moore offered a few examples of how pivot tables might be used to dig deeper into financial reports and zero in on potential problems:

1. Focus on overdue accounts. A general report on aging accounts receivable from your PM system might contain hundreds of pages, making it difficult to focus on specific trends. Exporting that data into pivot tables allows you to zero in on problem areas, such as claims overdue by 60 days categorized by insurer.

2. Gage productivity. If your compensation system is based on productivity, you can look at work relative value units by individual providers or during certain time periods.

3. Monitor workflow. Larger practices can monitor and compare activity at different locations. For example, how many patients did one employee register at a specific location vs. another employee at a different office? How many appeals or claims did each individual employee process at each office?

4. Analyze your patient base. Using a basic pivot table, you can see all of your new patients in a given year categorized by month of visit, referring physician, diagnosis code, insurance, or clinic location. Analyzing the data reveals trends, such as how many patients each physician saw in each year over the past five years.

5. Group data. You can group data to spot referral trends. For example, how many commercially insured patients did one group of referring physicians refer to each individual provider in your practice, for each of the past five years?

Adhering to patient safety standards is of vital importance when using an EHR, which is why proper review and research among different systems are critical for innovation. However, are supposed gag clauses in EHR vendor contracts inhibiting this kind of review and research?

A recent Politico article written by Darius Tahir presents considerable research into the matter. According to Tahir, EHR users are being completely prohibited from sharing adverse events and negative feedback regarding their EHRs. This stems from different gag clauses included in EHR vendor contracts, and seriously affects innovation that can help improve patient safety.

But HealthAffairsarticle by Kathy Kenyon, JD, MA, tries to clarify many of the legal implications of EHR vendor contracts, and discusses the realities of the “gag clauses.”

According to Kenyon, gag clauses in EHR vendor contracts do not necessarily prohibit users and researchers from offering negative feedback regarding their EHR systems. However, as soon as users or researchers include a screenshot of an EHR screen in their critique, they are breaching the “gag clauses” that actually deal with protecting intellectual property.

Kenyon states that many EHR vendor contracts include clauses that prohibit users from publically sharing screenshots of the EHR while reviewing the product without vendor permission. These clauses exist to protect the intellectual property of EHR vendors. However, they are actually quite vague and unclear, giving vendors the power to prohibit potentially vital research that could improve the EHR for patient safety.

“The true ‘gag clause’ problems with EHR vendor contracts appear to be related to the confidentiality and intellectual property terms, which are overbroad and unclear, and limits on ‘authorized uses’ of the EHR, as those terms apply to research and reporting that requires access to the EHR and use of screenshots,” she writes.

Furthermore, when researchers are able to access screenshots to share information for system improvement, vendors are given a high level of control regarding what system information is released. This potentially prevents unbiased information from being published, hindering the improvement process.

“As long as researchers must ask vendors for permission to do research or to publish screenshots, and as long as vendors can deny permission for any reason, including not liking the results, there is a serious danger that research will be designed and findings presented in ways that garner vendor permission,” she writes.

Kenyon points out that these clauses exist to protect the intellectual property of EHR vendors. The vendors are concerned that should information regarding the look and functionality of their software be released to the public, other vendors may steal these features. This would cause vendors to lose “competitive advantage,” Kenyon says, and would hurt the business of the EHR industry.

Kenyon says that many EHR users state that this fear of vendors is not entirely well-founded considering the ease with which competitors are able to gather information regarding a certain EHR.

“...it is not that hard to discover what different EHRs look like. For vendors hoping to improve their EHRs by ‘stealing’ from others, waiting for research with screenshots to be published would be an exceptionally inefficient way to do so,” she writes.

Furthermore, many physicians maintain that no price can be put on the safety of patients, Kenyon reports.

Kenyon maintains that under existing contracts, the provisions made to protect intellectual property are not functional for researchers. To increase patient safety while using EHRs, different standards are going to have to be implemented, Kenyon suggests.

“Stakeholder groups for patient and EHR safety, including parties to EHR contracts, should share interests in making health IT safety-related research and reporting as easy as possible,” Kenyon explains. “EHR vendor contracts should reflect as much consensus on these issues as is possible.”

She continues to provide suggestions for the construction of future EHR vendor contracts, stating that there should be no gag clauses, but rather clauses that encourage research and encourage reporting of adverse outcomes. By identifying these areas for improvement in EHR vendor contracts, research and adverse event reporting may potentially help increase patient safety.

October 1 has come and gone, and nearly two weeks in to ICD-10 compliance most of the healthcare industry is relatively mum on the transition to the newer clinical diagnostic and procedural code set. More than likely, healthcare organizations and professionals are busy enough adapting to ICD-10 and its more specific set of codes.

That’s not to say some are not speaking out or in support of ICD-10 compliance.

Two recent weekend reports in the Florida’s Crestview News Bulletin and Maine’s Bangor Daily News paint two very different pictures of ICD-10 compliance at the two-week mark.

Apparently, some physician practices in the Florida panhandle are going through the motions in adapting to the federal mandate for ICD-10 compliance which began back on October 1. Brian Hughes reports that medical offices are encountering difficulties with the code set.

“Large practices and medical companies, such as Peoples’ Home Health, usually have coders on staff. Their only job is to enter the numbers into billing records and insurance reimbursement forms,” he writes. “For smaller offices like Dr. Herf’s and Mir’s, the increased coding tasks take away staffers’ time with patients.”

Betty Jordan, the manager of physician practice of Abdul Mir, MD, views ICD-10 as more of a hindrance than a help.

“It requires so much extra work. If my doctor treated someone for rheumatoid arthritis, there’s hundreds of codes. It’s got to be specific,” she told the Crestview News Bulletin.

“It is horrible for a primary care doctor,” she further revealed. “For a specialist, they deal with the same things over and over. For us in family practice, we see all kinds of things. It’s overwhelming.”

For an administrator at the practice of David Herf, MD, the challenge of ICD-10 compliance is the result of increased specificity being married to an increase amount detail.

“It’s really, really detailed,” Andrew Linares told the news outlet. “Instead of just saying, ‘cyst of the arm or trunk,’ you have to get really specific.”

For one of the physician practices, adapting to ICD-10 is akin to learning a whole new language.

The climate in Maine appears much sunnier regarding ICD-10 compliance. Jen Lynds reports high levels of preparation among Maine healthcare organizations and professionals leading to a smooth transition.

“Health care providers across the state began working Oct. 1 with a new system of medical codes that has them describing illnesses and injuries in more detail than ever before, and officials from hospitals and medical associations said earlier this week that they are prepared for the challenge,” she writes.

According to Gordon H. Smith, the Executive Vice President of the Maine Medical Association, complaints are scarce as are ICD-10 implementation delays. Director of Communications for the Maine Hospital Association reports the same situation.

That being said, leadership at Eastern Maine Medical Center are preparing for transition-related productivity decreases for coders and billers used to the previous code set. However, things are still proceeding as planned.

“Our transition to ICD-10 has gone very smoothly here at Eastern Maine Medical Center,” Director of Coding and Clinical Documentation Improvement Mandy Reid told the Bangor Daily News. “We are using nine contract coders through outside vendors to support the ICD-10 go-live, and we secured them several months ago to be prepared. We also have added three positions in the outpatient area to help support growing volume, as well as ICD-10 coding.”

The lesson learned so far is that a clinical practice’s ability to invest in ICD-10 preparation (e.g., training) correlates to its present-day confidence in ICD-10 compliance.

"Ultimately, the data from this study demonstrate that during safety-critical tasks and times, patient safety is negatively affected, in part because mistakes and critical use errors occur more frequently and because users are highly frustrated, and thus more likely to employ workarounds, such as relying upon supplemental artifacts, e.g., paper ‘shadow charts’ or whiteboards," the authors conclude.

clinically relevant information being unavailable at the point of care

lack of adequate EHR clinical documentation

inaccurate information present in the clinical record

inability to retrieve clinical data

Based on empirical analysis of inpatient and ambulatory EHR use, the NIST document proposes three EHR usability enhancements that EHR technology incorporate to eliminate or reduce risks to patient safety.

The first centers of how critical patient identification data is presented. According to NIST, this information should be presented in a reserved area. The authors of the report recommended reserving the upper left-hand corner of all screens or windows and remain persistent regardless of scrolling or navigation throughout the EHR. Additionally, they hold that a patient's name appear with last name first, followed by first and middle names, modifiers, data of birth, age, gender, and medical record number (MRN) number. For EHR mobile technology, the NIST guidance allows for the presentation of this information horizontally to maximize screen space.

The second enhancement calls for the use of visual cues to "reduce risks of entering information and writing orders in the wrong patient's chart." The enhancement would prevent EHR users from entering information into multiple charts simultaneously as well as visually different between read-only and editable charts. Under this guidance, EHR users would have to deliberately enable the software to move between charts and maintain unrestricted access and provide clear cues when an EHR user moves between charts.

The third and final enhance places an emphasis on supporting the effective identification of "inaccurate, outdate, or inappropriate items in lists of group information by having information presented simply in a well-organized manner." The NIST document contains several examples:

3.1 Lists of patients assigned to a particular clinician user should be presented in consistent, predictable locations within and across displays and print-outs and the content should not vary based on display location.

3.2 The status of a note and order as draft as compared to final shall be clearly indicated on appropriate displays.

3.3 Clearly indicate the method by which the system saves information, whether auto-save or requiring deliberate action to save, or combinations thereof.

3.4 Inputted information should be automatically saved when a user transitions from one chart to another.

3.5 The language used should be task-oriented and familiar to users, including being consistent with expectations based upon clinical training.

3.6 Enable a user to easily order medications that have a high likelihood of being the appropriate medication, dose, and route. The likelihood is increased when displays are tailored to specialty-specific user requirements, comply with national evidence-based recommendations, are in accordance with system, organizational, unit, or individual provider preferences specified in advance, or are similar to orders made by the same physician on similar patients, on the same patient in the past, or providers with similar characteristics.

3.7 Support assessing relationships of displayed information and allowing users with appropriate permissions to modify locations and relationships for inaccurately placed information, including laboratory results, imaging results, pathology results, consult notes, and progress notes. This includes information within a single patient’s chart as well as information placed in the wrong patient’s chart. The information about the time and person that made the change should be viewable on demand.

On top of these recommendations, the guidance provides two use cases to illustrate the components of EHR usability testing in identifying and mitigating potential patient safety risks in both inpatient and outpatient settings.

Epic Systems is in the driver's seat compared to other ambulatory EHR vendors and poised to take control of an even larger portion of the outpatient EHR market, according to a recent survey of more than 170 ambulatory care facilities.

Conducted by peer60, the report shows Epic to control close to 20 percent of the ambulatory EHR market several points ahead of its main competitor Cerner Corporation, which owns less than 15 percent.

The authors of the report base their predictions for Epic's growth on the perceived market dominance of the Wisconsin-based EHR vendor — that is, "mindshare." Epic and Cerner are neck and neck among ambulatory care facilities in this area, hovering around 32 percent.

"As has been the case in past years, Epic’s and Cerner’s aggressive positions will continue to gobble up pieces of the ambulatory pie currently occupied by vendors that have struggled to stay relevant in this space," the report states.

Also likely to make gains are athenahealth and eClinicalWorks whose mindshare ranges between 14 and 20 percent:

The other half of the market share and mindshare story and equally impressive is athenahealth’s and eClinicalWorks’ significant mindshare figures at approximately eight and five times their current market share in the overall ambulatory EHR market, respectively. This indicates these vendors are finding significant ways to positively connect with providers.

According to the authors, the disparity between market share and mindshare indicates a need for EHR vendors to improve their standing among ambulatory care providers, a caveat being that EHR vendors focusing on independent facilities have less to lose because many ambulatory centers base their EHR selection on hospital EHR selection.

For these independents, Epic and Cerner trail NextGen based on market share, the latter holding close to 20 percent of the marketplace. As for mindshare, NextGen's prospects are not good "considering they occupy no space in the future plans of independent ambulatory providers," the authors contend. Meanwhile, eClinicalWorks is set to make major gains among these ambulatory care settings well ahead of both Epic and Cerner.

Factoring in to future ambulatory EHR selections will be EHR vendor recommendation scores from providers. On average, ambulatory providers are more likely than not to recommend their current ambulatory EHR technology to others — 6.2 out of 10. The scores for individual EHR vendors is not made public, but five vendors scored above the 6.2 mark with one scoring as high as 9.3.

What will likely influence ambulatory EHR selections are solutions to the top challenges for provider EHR users. The top EHR challenges are missing EHR functionality (55%), lack of EHR usability (42%), and support of a practice's strategic objectives (30%).

Despite these responses, the ability of EHR vendors to make inroads in the ambulatory care setting will be difficult. A vast majority of respondents (85%) are not actively looking for EHR replacement technology. This is the case for both hospital-owned and independent ambulatory facilities.

It happened. The switch flipped and on Oct. 1, our healthcare system went from around 14,000 diagnostic codes to 68,000 codes with the final implementation of ICD-10. No “Y2K”-style catastrophe. No computer system meltdowns.

We will now be watching for the long-term effects of this change. Will the processing of payments for healthcare services in the United States be adversely affected by this transition? We won't know the answer to this for some time.

As the EHR guru for my private practice, I have been responsible for the transition on the local level. This means making sure that our software is up to date and ready, and our various billing documents and their associated procedures are ready to communicate ICD- 10 information to our billers.

Additionally, as an EHR "superuser" on the medical staff of my community hospital, I watched transition issues and steps very closely in preparation for the transition. I have to say that I have been pleasantly surprised with both the administration of the hospital, as well as with the IT folks and on-site EHR vendor staff, in making this transition as painless as possible.

I have written before about how, in this phase of EHR development, the EHR has focused on the needs of the system (i.e. meaningful use, billing, etc.) and not the needs of the providers in making the process of documenting our care as smooth and easy as possible. In the most recent major upgrade to the industrial strength EHR system, significant strides forward were achieved in making the providers’ lives easier.

The first was to make customizable specialty view landing pages that facilitated EHR use to document patient encounters in a very linear and intuitive process. I have been documenting patient care with the EHR for more than three years now, and this one change was a huge step forward in using my time efficiently on rounding in the hospital.

The second major change in the hospital's EHR was simplifying the coding tool. From within the landing page, you just click on diagnosis, and start with a simple search term like "breast neoplasm." This immediately presents you with vertical lists in columns, from left to right. As you make choices in the columns (e.g., disease specifics, anatomical location, laterality, etc.) the choices rapidly narrow, and the coder lets you know through visual clues when there is sufficient information for a complete ICD-10 code. Whoever designed this deserves a medal.

I have worked with physicians and showed them how to use the landing page, as well as the diagnosis tool, and early and late adopters have both been able to adjust their way around the software quickly - indicating a sign of intelligent, user-friendly design.

I have been told by the vendor support staff that the new focus on supporting the needs of the providers will bring tablets and tools to the floor of the hospital, which will make the end user experience much better, time efficient, and useful. This has not happened just yet – one step at a time - but I remain bullish on the promise of the EHR.

I'm hopeful that the world of the EHR is moving to a new phase; a phase that focuses more on making the processes of documenting patient care easier, faster and more intuitive. Good data flows uphill, and makes the other outputs of the EHR more cohesive. The coming weeks, months, and years will ultimately tell the tale of this transition to ICD- 10, but I’m hopeful that it will ultimately give us the information and data we need to make a difference in the healthcare system and in the lives of our patients.

As the waiting game for the Stage 3 Meaningful Use final rule and Stage 2 modification rule continues, the American Medical Association (AMA) is calling on the Centers for Medicare & Medicaid Services (CMS) to start taking actions to account for their delay. According to a recent press release, AMA is asking CMS to make an automatic hardship exemption due to the delay in the final rule’s release.

According to AMA President Steven J. Stack, MD, many physicians with the AMA are concerned that they will not be able to meet meaningful use standards because the details of the Stage 2 modification rule have not yet been released.

“The AMA has regularly stressed that CMS must finalize Meaningful Use modifications well ahead of Oct. 1 to provide the time that physicians need to plan for and accommodate these changes, yet CMS has continued to delay finalizing this rule,” says Stack. “As a result, many physicians who were counting on this flexibility will be subject to financial penalties under the rules currently in place.”

An automatic hardship exemption would exempt providers of financial penalties if they are not able to meet certain meaningful use standards. CMS developed hardship exemptions for providers who can demonstrate that adhering to meaningful use rules would cause a considerable hardship. AMA maintains that the considerable delay in the final rule is viable cause for an automatic hardship exemption.

The AMA is not the only organization expressing distress over the meaningful use final rule. Many entities, such as the Medical Group Management Association (MGMA) are calling on CMS to extend the meaningful use reporting period due to the delayed final rule.

The organization is concerned that medical groups will not have time to report for the final 2015 reporting period if not given adequate notice of the new EHR Incentive Program modifications.

MGMA stated that even if the modifications rule had been announced in early September, providers still would not have had adequate time to adjust workflows for the final reporting period beginning on October 3. Instead, MGMA suggested CMS extend the reporting period to either the first 90 days of 2016, or the final 90 days of 2015.

Other entities, such as the College of Healthcare Information Management Executives (CHIME), have simply urged CMS to release the modification final rule sooner. CHIME, in addition to several other co-signing industry stakeholders, states that CMS withholding the final rule is preventing providers from having adequate time to prepare to the program modifications.

CHIME reiterated that many industry stakeholders commend CMS’ efforts to refocus meaningful use standards, but feels as though inadequate time is being given to providers to make their own adjustments in time for the October 3 final reporting period.

As the final reporting period is mere days away, CMS will need to release the final rule for the meaningful use modifications soon, or many providers will be left unable to meet the final reporting deadline.

The Leidos-led team that won the Department of Defense Healthcare Management System Modernization (DHMSM) award — that is, the DoD EHR modernization project — has made another addition to its squad for the purposes of health IT integration and health information exchange.

The Leidos Partnership for Defense Health now includes Orion Health as a subcontractor, the health IT company announced Monday.

"Orion Health is proud to be part of the Leidos Partnership for Defense Health, the team that has been selected as the best value solution for the DHMSM contract," President Paul Viskovich said in a public statement.

"Together, our qualified and experienced team is working with the Department of Defense to deliver a world class interoperable electronic health records solution for our nation’s armed forces, their families and beneficiaries," he continued. "We look forward to the work ahead and are committed to improving access to comprehensive healthcare data in order to facilitate improved clinical outcomes for our deserving men and women in uniform."

According to the statement, the partnership is looking to take advantage of the company's health IT integration engine to facilitate the exchange of health data between the DoD Cerner EHR and the health IT systems of non-military healthcare organizations and providers.

The focus now appears to be shifting to the technical nuts and bolts of ensuring that health data flows inside and outside the Military Health System, a decisive factor in the Leidos bid winning the DHMSM contract.

"Cerner’s demonstration of wide-ranging provider interoperability on multiple, different platforms were the huge differentiator over Epic’s garden-walled methodology to system user data sharing," Black Book Managing Partner Doug Brown told EHRIntelligence.com when the contract was awarded.

As part of the Leidos-led bid, Cerner beat out rivals Epic Systems and Allscripts for the project that could approach $10 billion when all is said and one.

"The DoD's requirements are unique, which makes comparisons difficult, but pricing was surely a critical factor in the DoD decision," the research organization stated. "IDC Health Insights views the pricing of the winning bid as having come in quite low when compared with commercial EHR contracts in recent years. This gives the DoD the potential to realize higher ROI from its EHR investment than is likely possible at many private health systems."

The company will be hosting its annual user conference next week and new details about the DoD EHR modernization project are likely to emerge.

Automating extraction of data from electronic health records (EHRs) is an excellent idea. Done right, it can provide a complete data set, something not possible with the sampling methods used in the current labor-intensive hand extraction used for reporting many hospital quality measures. A complete data set, if accurate, is far more useful than a sample set in population analytics and in efforts to bring greater precision to medical treatment protocols.

Unfortunately, the data set is seldom accurate. A disconnect between EHR vendor tools and the way the EHRs are implemented has been a big barrier to pulling accurate data out of patient medical records. The programmers who create the vendor tools work under the assumption that data are entered in a particular field and at a particular point in the treatment process. But end users can be amazingly creative in their use of EHRs, especially when they are resistant to changing their workflows. Without consistent, strong governance over EHR adaptations, healthcare organizations can end up with numerous, often undocumented, variations and customizations of their software. And many of those variations are adaptations that the application coders never imagined. The result is extraction tools that can’t find relevant data.

Adding to this problem is the consistent inconsistency of how data are entered, especially in departments where traffic is high and work is fast-paced. Demographic details, which are important to identifying all relevant patients for a particular measure, are often overlooked. Sometimes data that should be entered in a particular field are recorded in unstructured notes, making it invisible to the automated tool.

Unlike experienced human chart reviewers, who can search out missing data, or infer essential qualifying data points through unstructured notes, automated tools are seldom sophisticated enough to find the missing data. That’s why there are often big discrepancies between the data reported to attest to Meaningful Use (MU) extracted by automated tools and what those data would show if manually extracted by an expert reviewer. This disparity is more conspicuous when comparing automated reporting of whole population measures, as with Meaningful Use, and manually sampled population measures, as with the Inpatient Quality Measures. As the Centers for Medicare & Medicaid Services (CMS) attempts to synchronize the various quality measure reporting programs within Health and Human Services, this issue will need to be tackled.

It’s time to pay attention to inaccurate data extraction

Up to now, this hasn’t been an urgent issue for many hospitals. So far, MU criteria has only required them to certify that the data are calculated within and reported from certified technology, not reconcile disagreements they may have between system-generated numbers and what they may believe is truly representative of a particular measure population. For example, the certified EHR may return a zero in a measure numerator when the clinical team and quality staff “know” patients should qualify based on the measure definition. Up to now, the quality of their care has not been judged on these data and it has had no effect on their reimbursement rates or their MU incentive rewards. It has been seen as a bit of CMS wheel-spinning by many, and with many other more-urgent issues on their plates, quality officers, IT staff and c-suite leaders have been satisfied with noting the problem and moving on to other things that matter more.

But the time has come to pay more attention to this issue. CMS is quickly moving toward requiring electronic submission of the extracted data, which is the first step toward public reporting of the data and using it to calculate performance-based payments. In the near future, your reputation and your bottom line will depend on the accuracy of these data. At a minimum, you want system-reported numbers to reasonably reflect what you think is your true performance on these measures.

You don’t want to wait until that future arrives on your doorstep. Trouble-shooting extraction tool errors is not a job that can be rushed. It requires patience, diligence and teamwork, all of which are hard to muster in a frantic, last-minute dash to fix the problem. If you haven’t started working on this problem, now is the time to spin up a team and get started.

This isn’t an IT project!

While your IT staff will be an important part of the team, troubleshooting an extraction tool is not an IT project. Ideally, you need to involve your quality staff, your informatics staff, your IT staff and your EHR vendor. Because the problems often lie in a mismatch between the idealized implementation and the real-world adaptions that are inevitable, quality staff and informatics staff must be involved. You need people who are intimately familiar with the clinical workflows, especially where essential data points should be captured, to help you identify where the problems lie.

You also have to collaborate with your EHR vendor. If the problem lies in the coding or the algorithms of the tool, you may not be able to see that on your own. You’ll need to work with the people who created the tool – the application coders – to identify those problems. If your vendor isn’t responsive, be insistent. While the vendors with the deepest pockets have put significant time and effort in working with hospitals on this issue, others with fewer resources may be reluctant to dedicate the time and effort needed. With these vendors, be adamant that they do so. They sold you the EHR with the extraction tool and it is their responsibility to help you get it right.

Connect with other users to gain insights

Chances are that if you are experiencing a problem in your data extraction, other organizations that use the EHR are having similar difficulties. Consult the user forums or community sites offered by the vendor to see if anyone has found a solution or can help identify the root of the problem. Contact your peers at other hospitals in your system to see what their experience has been. In my work with hospital systems, I am often amazed at how often important information like this just isn’t shared. People solve a problem and move on, forgetting that their sister hospitals may also be struggling with the issue. So don’t be shy about sharing either your data woes or your solutions. It really does take the whole healthcare community to troubleshoot extraction issues! At the end of the day, the effort is worth it. Our goal is to build a robust analytics capability—with trustworthy data—that clinical teams can use to better understand patient outcomes. Their ability to continuously improve care and deliver the positive patient outcomes we all desire is directly tied to the accuracy of the data extracted from your EHR.

The latest hearing held by the Senate Committee on Health, Education, Labor & Pensions (HELP) resulted in more than the call to delay Stage 3 Meaningful Use. It also provided numerous methods that federal legislators and healthcare organizations can take to improve patient access to health information.

Each of the three witnesses offered insight into the barriers preventing patients from having timely access to their health information in a highly useable electronic form.

First up was Raj Ratwani, PhD, who serves as Scientific Director at National Center for Human Factors in Healthcare at MedStar Health and Assistant Professor of Emergency Medicine at Georgetown University School of Medicine.

For Ratwani, the major issue surrounding patient access to health information is usability.

"Patients must have easy access to their health information to improve health outcomes, facilitate patient and family engagement in care, and to reduce safety risks. Critically, this information must be presented in a manner that is both understandable and useful," he stated in his opening remarks.

In comments specific to the critical nature of patient use of health IT, Ratwani identified three critical factors: access, functionality, and information quality.

Of the first, he noted that patients "should be able to easily access all of their health information, securely, and in one place" and that "interoperability is crucial to patient access."

Of the second, he emphasized the need for user-centered design when presenting health information to patients and making patient engagement a part of the clinician's workflow.

"The information and capabilities of the system must be useful for the patient," he stated. "The design of system capabilities, such as patient-provider communication, should be intelligently integrated with the workflow processes of the clinician so that the clinicians are able to support the patient in a timely manner."

Lastly, Ratwani tied to quality of information to its usefulness to patients. "Information must be accurate and meaningful to the patient, presented in a manner that can be easily understood, and that will help them gain insights," he added.

According to a second witness, Kathy Giusti, MBA, Founder and Executive Chairman of the Multiple Myeloma Research Foundation, the potential of patient health IT to improve health outcomes hinges of EHR integration, aggregation, and sharing of data.

For Giusti, patient engagement begins with education to ensure that patients are aware of the tools available to them to help manage their own care. "Physicians, hospitals, advocacy organizations, and the government must ensure that patients are educated on how best to use the technology," shenoted.

EHR integration plays an important picture in enabling providers to have a complete picture of a patient's health at the point of care rather than having to access disparate sources of clinical data.

"The greatest efficiency will come from our ability to integrate EHRs across the vast number of specialized doctors and centers that patients now see," she maintained. "That data must be integrated into a centralized portal that we as patients feel like we own, share, update, and provide."

Giusti's final observation on patient access to health information centered on the importance of analyzing large stores of health information for research purposes, such as in her organization's work on cancer.

"The ability to understand, integrate, aggregate and analyze EHRs is on the critical path to improving outcomes and accelerating cures. We have shown the impact of data sharing in one uncommon, fatal disease," she closed.

The hearing's third witness shifted the focus of patient access to information to Congressional intervention. In his opening remarks, Intel Felllow and General Manager for Health and Life Sciences at Intel Corporation Eric Dishman called on Congress to do four things:

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